eviCore review requirement

These coverage policies are used by medical directors and other professionals in making medical necessity and other coverage determinations for Cigna-administered plans; certain high‑tech imaging procedures are reviewed by eviCore per the Cigna CPT code list. In the event of conflict, the applicable benefit plan document supersedes the policy.

Prior authorization applies to listed pelvic imaging CPTs

Prior authorization and review processes apply to the listed pelvic imaging CPTs identified in the guideline (for example, 3D/4D ultrasound rendering CPTs 76376/76377 and pelvic MRI CPTs 72195/72196/72197) when requested in the specified scenarios.

Advanced cross-sectional imaging requires prior justification

CT pelvis (e.g., CPT 72194) or MRI pelvis (CPT 72195/72197) should only be obtained when ultrasound (with color Doppler) is equivocal and further cross‑sectional imaging is needed for surgical planning or to resolve indeterminate results.

Prior authorization for MRI/MRA/CTA when ultrasound inconclusive or for procedural planning

MRI (CPT 72195/72197) and vascular cross‑sectional imaging (MRA CPT 72198 or CTA CPT 72191) are medically necessary as second‑line studies when ultrasound is inconclusive or when required for interventional/embolization planning.

Imaging follow-up and MRI authorization

Follow‑up pelvic/transvaginal ultrasound (CPT 76830, 76856, 76857) is supported per the guideline schedules; MRI Pelvis without and with contrast (CPT 72197) is medically necessary when indicated (e.g., equivocal ultrasound, solid component, changing morphology).

Prior authorization expectations

MRI Pelvis (CPT 72195 or 72197) is medically necessary only for specified indications (e.g., preoperative planning for deep pelvic endometriosis, characterization of complex adnexal masses when ultrasound is equivocal); documentation must support the specific indication.

Imaging prior authorization considerations

Pelvic ultrasound (CPT 76856/76857 or 76830) and/or color Doppler (CPT 93975/93976) are medically necessary as initial imaging when diagnosis remains uncertain after exam and labs; CT or MRI require justification when ultrasound is inconclusive or for abscess/TOA planning.

Imaging prior authorization guidance

A one‑time pelvic ultrasound (CPT 76856/76857) and/or transvaginal ultrasound (CPT 76830) is medically necessary for initial infertility evaluation; CT or MRI for lost IUD localization is medically necessary only when ultrasound and plain x‑ray are negative or non‑diagnostic.

Prior authorization for advanced pelvic imaging

Obtain prior authorization per payer rules when ordering CT pelvis with contrast (CPT 72193) or MRI pelvis (CPT 72195/72197) for chronic pelvic pain, surgical planning, or other advanced pelvic imaging after equivocal ultrasound.

Advanced vascular imaging for planning

For embolization or other vascular procedural planning, MRI pelvis (CPT 72195/72197) may be used; if MR is equivocal or the interventionalist requests vascular mapping, MRA (CPT 72198) or CTA (CPT 72191) may be obtained with prior authorization as indicated.

Prior authorization for specified advanced imaging

Advanced imaging such as MRI Pelvis (CPT 72197) and certain CT/MRI abdomen or pelvis studies are medically necessary in defined situations (e.g., surgical planning, indeterminate ultrasound) and are subject to payer prior authorization processes.

Prior authorization for select MRI studies

Per eviCore rules, fetal MRI (CPT 74712) and Whole Body MRI (CPT 76498) require prior authorization per the guideline when requested in the described clinical sequences.

Whole Body MRI for unexplained abnormal NIPT

Whole Body MRI (CPT 76498) is authorized when targeted fetal and maternal workup are completed and unrevealing for abnormal NIPT suggesting possible maternal malignancy.

Embolization imaging inclusivity

CPT 37243 (vascular embolization) includes radiological supervision/interpretation, intraprocedural roadmapping, and imaging guidance required to complete the intervention; additional advanced imaging codes during the procedure are not medically necessary.

Preprocedural Vascular Imaging for PAE

When prostate artery embolization (PAE) is planned, MRA pelvis (CPT 72198) or CTA pelvis (CPT 72191) is medically necessary for preprocedural evaluation of pelvic vasculature; document that vascular mapping was ordered for PAE planning.

• MRA (CPT 72198) or CTA (CPT 72191) required for PAE planning
• Document vascular evaluation ordered as part of PAE planning

Imaging step requirement

Non‑advanced imaging (e.g., pelvic/transvaginal ultrasound) and appropriate laboratory testing are expected prior to ordering advanced imaging when clinically appropriate; perform and document initial workup before escalation.

Imaging modality sequencing

Ultrasound is recommended as the first‑line imaging modality for female pelvic disorders; reserve MRI as a second‑line or problem‑solving modality when ultrasound is inconclusive or specific indications are met.

Begin with pregnancy testing and ultrasound before advanced imaging

Begin with pregnancy testing and pelvic/transvaginal ultrasound before advanced imaging; add color Doppler and 3‑D rendering as adjuncts when ultrasound is equivocal and prior to CT/MRI if clinically appropriate.

Initial imaging should be ultrasound before MRI except specific circumstances

Initial imaging for most pelvic indications should be ultrasound (transvaginal or transabdominal); MRI is reserved for defined situations (e.g., pregnancy where MRI without contrast preferred, indeterminate ultrasound, surgical planning).

Ultrasound before MRI for adnexal masses

When ultrasound incompletely evaluates a complex or solid adnexal mass, repeat ultrasound is generally medically necessary; a single MRI Pelvis without and with contrast (CPT 72197) is medically necessary in specified situations (e.g., poor visualization, unexplained change, O‑RADS 3 with solid component, O‑RADS 4–5).

Imaging step therapy

Stepwise imaging approach: perform transabdominal and/or transvaginal ultrasound first; reserve MRI for the listed indications when ultrasound is indeterminate or for surgical planning.

Ultrasound first for PID and PCOS; labs before advanced imaging

Recommend initial use of pelvic transabdominal and/or transvaginal ultrasound before CT or MRI for evaluation of PID and PCOS; obtain recommended laboratory testing (e.g., virilizing hormones for PCOS) prior to advanced imaging.

IUD localization workflow: ultrasound → X‑ray → CT/MRI

For suspected malpositioned or 'lost' IUD perform ultrasound first; if ultrasound is non‑diagnostic and pregnancy test is negative, obtain plain X‑ray; if both ultrasound and X‑ray are equivocal, escalate to CT or MRI to delineate position.

• Ultrasound initial
• If US non‑diagnostic and pregnancy negative → X‑ray
• If US + X‑ray equivocal → CT or MRI

Ultrasound required as initial step; document pregnancy test

Ultrasound (transabdominal and/or transvaginal) is required as the initial imaging step before advanced modalities for suspected gynecologic pelvic pain or malpositioned IUD; document pregnancy test for premenopausal patients.

Transvaginal ultrasound as initial study for uterine mass

Transvaginal ultrasound (CPT 76830) is the medically necessary initial study for suspected uterine mass; pelvic ultrasound (CPT 76856/76857) may be complementary before advancing to MRI for indeterminate findings or surgical planning.

Ultrasound often first-line but not always mandatory

Ultrasound is appropriate initial imaging for many indications but is not always required prior to advanced imaging (e.g., urethral diverticula may proceed to urethrography/CT or MRI without a mandatory prior ultrasound when clinically appropriate).

Stepwise imaging approach

Stepwise imaging: begin with ultrasound (including 3‑D when appropriate); proceed to MRI or CT only when ultrasound is indeterminate or additional detail for surgical planning is required.

Required stepwise workup before Whole Body MRI for abnormal NIPT

Complete prerequisite fetal evaluation (detailed fetal anatomy scan and invasive fetal testing if applicable) and targeted maternal clinical/laboratory workup and imaging before authorizing Whole Body MRI when abnormal NIPT suggests maternal‑origin anomalies.

• Detailed fetal anatomy scan and fetal testing (amniocentesis/CVS) if indicated
• Complete maternal history, physical, labs and targeted imaging
• Proceed to Whole Body MRI (CPT 76498) only if targeted workup unrevealing

Stepwise imaging approach for male pelvic/penile indications

For penile lesions, ED, and male pelvic pain start with ultrasound; advance to CT/CTA/MRI/MRA only if ultrasound is equivocal, nondiagnostic, or vascular/oncologic evaluation or procedural planning is required.

Imaging Stepwise Requirement for male pelvic pain/prostate

Perform transabdominal pelvic ultrasound (CPT 76856/76857) as initial imaging for male pelvic pain/prostate evaluation; proceed to CT pelvis with contrast (CPT 72193) or MRI pelvis (CPT 72195/72197) only if ultrasound is equivocal or nondiagnostic.

Required clinical evaluation before advanced imaging

A current clinical evaluation since onset or change in symptoms is required before advanced imaging; acceptable elements include history, pelvic/urologic exam, appropriate labs, and non‑advanced imaging such as plain x‑ray or ultrasound.

Acceptable substitute for in‑person evaluation

Other meaningful contact (telehealth, telephone, electronic messaging) since onset or change in symptoms by an established individual may substitute for a face‑to‑face clinical evaluation.

Coding guidance for 3D rendering and pelvic MRI

When billing for 3‑D rendering report CPT 76376 or 76377 as appropriate; report MRI pelvis with CPT 72195, 72196, or 72197 depending on contrast protocol per the guideline and payer coding rules.

Pregnancy test and documentation requirements

Pregnancy test result must be documented for premenopausal patients when imaging for pelvic indications (e.g., pelvic pain, IUD localization); if pregnancy test is positive, obstetrical CPT coding is required instead of gynecology CPTs.

• Document pregnancy test result prior to imaging in premenopausal patients
• If positive, use obstetrical CPT codes and follow obstetrical imaging policy

Document indication, relevant exam findings, prior imaging

Ordering documentation should include the clinical indication, relevant exam findings (e.g., suspected mass, simple versus complex cyst features), prior ultrasound results if repeating, pregnancy status, and whether transvaginal approach is acceptable/consented.

Pre‑menopausal and post‑menopausal evaluation labs and tests

For pre‑menopausal evaluation consider pregnancy test (quantitative hCG if ectopic suspected), CBC/hematocrit, and cultures as clinically indicated; for post‑menopausal evaluation obtain tumor markers (e.g., CA‑125) when evaluating complex cysts or solid masses.

Required clinical documentation to support MRI requests

Ordering documentation must support first‑line use of transvaginal and/or transabdominal pelvic ultrasound and explicitly state the reason for MRI when requested (e.g., planned surgery for deep infiltrative endometriosis, indeterminate adnexal mass after US, suspected extrapelvic endometriosis, or inconclusive ultrasound for abdominal wall/cesarean scar disease).

Documentation should include clinical exam findings and lab results

Documentation should include clinical examination findings, results of laboratory testing (e.g., WBC, CRP, ESR, microscopy of vaginal secretions, testing for N. gonorrhoeae and C. trachomatis), and rationale for advanced imaging if ultrasound is inconclusive or TOA suspected.

Pregnancy test documentation for lost IUD imaging

Pregnancy test result must be documented when imaging for a lost IUD; a positive pregnancy requires obstetrical coding and different supported imaging workflows.

Document pregnancy test result and initial ultrasound findings

Document pregnancy test result for premenopausal patients and initial ultrasound findings; if ultrasound is equivocal, document the rationale for proceeding to X‑ray (for IUD) or CT/MRI for pelvic pain evaluation.

Negative pregnancy test and sampling guidance for leiomyoma/endometrium

A negative pregnancy test is required for premenopausal patients when ultrasound is performed for suspected leiomyoma with symptoms or enlarged uterus on exam; individualized assessment including endometrial sampling is medically necessary for postmenopausal thickened endometrium (>4 mm).

Document clinical indication and prior imaging to support advanced imaging

Clinical indication and prior imaging results should be documented to support the use of advanced imaging modalities (e.g., ultrasound indeterminate or imaging requested for surgical planning).

Documentation for abnormal NIPT workup

Complete clinical workup documentation (history, physical, labs, tumor markers, targeted imaging) is required to support proceeding to Whole Body MRI when abnormal NIPT persists without an identified maternal source.

• History and physical
• CBC, peripheral smear, LDH, liver and renal function
• Appropriate tumor markers and targeted imaging results

Workup documentation before Whole Body MRI

Document complete history, physical exam, and results of appropriate laboratory testing (CBC, peripheral smear, LDH, liver and renal function, tumor markers) and targeted imaging results before whole body MRI is authorized when abnormal NIPT suggests possible maternal malignancy.

Documentation should include clinical indication and initial ultrasound results

Clinical documentation should include the indication (e.g., suspected ED, priapism duration, biopsy‑proven penile cancer, suspected prostate abscess or BPH with obstructive symptoms, molar pregnancy and hCG trend) and results of initial ultrasound when performed to support advanced imaging or procedural vascular mapping.

Required clinical documentation (proctalgia and pelvic pain)

Clinical documentation should include history, physical exam findings, and results of initial ultrasound (when performed). For proctalgia, document digital rectal exam and recent sigmoidoscopy/colonoscopy or clinical/lab evidence prompting imaging.

PAE Imaging Documentation

For PAE planning, documentation should indicate that MRA or CTA pelvis was ordered for vascular evaluation as part of preprocedural planning; note that CPT 37243 includes intraprocedural imaging.

Coverage determinations and plan document precedence

Coverage determinations require consideration of the applicable benefit plan document, laws/regulations, and relevant collateral materials; failure to follow plan terms or applicable rules may trigger denial.

CT not medically necessary for pelvic anatomy

CT is not medically necessary for evaluating pelvic anatomy due to limited soft tissue contrast resolution; use of CT as a primary modality for pelvic soft‑tissue evaluation may trigger denial.

MRI not appropriate as initial imaging for AUB

Requests for MRI as initial imaging for abnormal uterine bleeding or routine CT for AUB may be denied when ultrasound is the indicated first‑line modality; MRI is not indicated as initial imaging for AUB per the guideline.

Routine 3D rendering for simple cysts not medically necessary

Routine use of 3‑D rendering (CPT 76376/76377) for evaluation of simple ovarian cysts is not medically necessary and may be denied; reserve 3‑D rendering for the specified indications where it is described as medically necessary.

Indication-based MRI authorization risk

Use of MRI must align with specified indications (e.g., preoperative planning for deep pelvic endometriosis, characterization of complex adnexal masses after inconclusive ultrasound); requests outside those indications risk denial.

Failure to show uncertainty after exam/labs may risk denial

Failure to document that the diagnosis remained uncertain after clinical exam and laboratory testing when ordering pelvic ultrasound, CT, or MRI for suspected PID or TOA may lead to denial of imaging requests.

Repeat/serial ultrasounds for infertility not medically necessary

Repeat or serial ultrasounds for initial infertility workup are designated not medically necessary and may be denied; only a one‑time pelvic/transvaginal ultrasound is medically necessary for initial infertility evaluation.

Gynecology CPTs not supported in pregnancy

Use of gynecology CPT codes for pregnant women is not supported; obstetrical CPT codes must be used if pregnancy test is positive — using non‑obstetrical CPTs in pregnancy may trigger denial.

Failure to document pregnancy test may lead to inappropriate imaging

Failure to document a pregnancy test in premenopausal females prior to imaging for pelvic pain may lead to inappropriate imaging selection and potential denial; always document pregnancy status.

CT not appropriate for pelvic soft‑tissue anatomy

CT is not medically necessary for evaluating female pelvic anatomy because of limited soft tissue contrast resolution; ordering CT as the primary modality for pelvic soft‑tissue evaluation risks denial.

Advanced imaging not medically necessary for known arcuate uterus

Advanced imaging for a known arcuate uterus is not medically necessary and claims for advanced imaging solely for a confirmed arcuate uterus may be denied.

Denial risk for incomplete abnormal NIPT workup

Failure to complete the recommended maternal workup (history, physical, labs, targeted imaging) or failure to perform whole body MRI when targeted workup is unrevealing in abnormal NIPT cases may lead to denial of whole body MRI or alternative imaging requests.

Risk when advanced imaging ordered without equivocal ultrasound

Ordering advanced imaging (CT or MRI) when initial ultrasound is not equivocal or nondiagnostic may not meet the guideline's stepwise requirement and could risk denial; document why ultrasound was insufficient.

Initial Ultrasound Requirement — perform and document

Failure to perform or document an initial transabdominal pelvic ultrasound when indicated may lead to denial if advanced imaging is requested without ultrasound being equivocal or nondiagnostic.